Laparoscopic repair of perforated duodenal ulcers: the simple "one-stitch" suture with omental patch technique

Laparoscopic versus open repair of perforated peptic ulcers: analysis of outcomes and identification of predictive factors of conversion

BACKGROUND

The surgical treatment for perforated peptic ulcers (PPUs) can be safely performed laparoscopically. This study aimed to compare the outcomes of patients who received different surgical approaches for PPU and to identify the predictive factors for conversion to open surgery.

METHODS

This retrospective study analyzed patients treated for PPUs from 2002 to 2020. Three groups were identified: a complete laparoscopic surgery group (LG), a conversion to open group (CG), and a primary open group (OG). After univariate comparisons, a multivariate analysis was conducted to identify the predictive factors for conversion.

RESULTS

Of the 175 patients that underwent surgery for PPU, 104 (59.4%) received a laparoscopic-first approach, and 27 (25.9%) required a conversion to open surgery. Patients treated directly with an open approach were older (p < 0.0001), had more comorbidities (p < 0.0001), and more frequently had a previous laparotomy (p = 0.0001). In the OG group, in-hospital mortality and ICU need were significantly higher, while the postoperative stay was longer. Previous abdominal surgery (OR 0.086, 95% CI 0.012-0.626; p = 0.015), ulcer size (OR 0.045, 95% CI 0.010-0.210; p < 0.0001), and a posterior ulcer location (OR 0.015, 95% CI 0.001-0.400; p = 0.012) were predictive factors for conversion to an open approach.

CONCLUSION

This study confirms the benefits of the laparoscopic approach for the treatment of PPUs. Previous laparotomies, a greater ulcer size, and a posterior location of the ulcer are risk factors for conversion to open surgery during laparoscopic repair.

An Overview of Gastroduodenal Perforation

Gastroduodenal perforation may be spontaneous or traumatic and the majority of spontaneous perforation is due to peptic ulcer disease. Improved medical management of peptic ulceration has reduced the incidence of perforation, but still remains a common cause of peritonitis. The classic sub-diaphragmatic air on chest x-ray may be absent and computed tomography scan is a more sensitive investigation in the stable patient. The management of perforated peptic ulcer disease is still a subject of debate. The majority of perforated peptic ulcers are caused by Helicobacter pylori, so definitive surgery is not usually required. Perforated peptic ulcer is an indication for operation in nearly all cases except when the patient is asymptomatic or unfit for surgery. However, non-operative management has a significant incidence of intra-abdominal abscesses and sepsis. Primary closure is achievable in traumatic perforation, but the management follows the Advanced Trauma Life Support (ATLS) principles.

Single-Port Laparoscopic Repair of Perforated Duodenal Ulcers

BACKGROUND

Laparoscopic single-port surgery has widely been introduced for the treatment of various abdominal conditions. But controversies still exist regarding its potential advantages and risks, especially for emergency surgery. The aim of this study was to evaluate the results of a single-port laparoscopic repair using straight laparoscopic instruments for the treatment of perforated duodenal ulcers.

METHODS

A prospective consecutive case series was conducted including all patients with a perforated duodenal ulcer who underwent a laparoscopic single-port repair at a single institution from January 2012 to June 2018. The operation was performed through a single port using conventional straight laparoscopic instruments and intra-corporeal knot tying techniques.

RESULTS

Out of 75 patients, simple closure of the perforation without omental patch was accomplished in 96% of cases. Conversion to an open operation was required in one patient (1.3%) due to a posterior duodenal perforation, and additional trocar placement was needed in another patient (1.3%). The mean incision length was 2.0 ± 0.2 cm. The mean operation time was 63.0 ± 26.6 min. Meantime a nasogastric tube remained in place was 2.9 ± 0.8 days. Mean duration of analgesic use was 2.8 ± 0.8 days. The rate of postoperative complications was 2.7%, including two patients with wound infections. There were no instances of intestinal leak or abscess. The postoperative hospital stay was 5.7 ± 1.2 days.

CONCLUSION

Laparoscopic single-port repair using conventional straight laparoscopic instruments with intra-corporeal knot tying technique was safe and feasible for patients with perforated duodenal ulcers with low risk factors. This method offers results comparable to those expected with the standard multiport laparoscopic approach with the addition of improved cosmetic outcomes.

LAPAROSCOPIC TECHNOLOGIES IN SURGERY OF PERFORATED GASTRODUODENAL ULCERS

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Perforated Peptic Ulcer Repair: Factors Predicting Conversion in Laparoscopy and Postoperative Septic Complications

OBJECTIVE

The surgical treatment for perforated peptic ulcers can be safely performed laparoscopically. The aim of the study was to define simple predictive factors for conversion and septic complications.

METHODS

This retrospective case-control study analyzed patients treated with either laparoscopic surgery or laparotomy for perforated peptic ulcers.

RESULTS

A total of 71 patients were analyzed. Laparoscopically operated patients had a shorter hospital stay (13.7 vs. 15.1 days). In an intention-to-treat analysis, patients with conversion to open surgery (analyzed as subgroup from laparoscopic approach group) showed no prolonged hospital stay (15.3 days) compared to patients with a primary open approach. Complication and mortality rates were not different between the groups. The statistical analysis identified four intraoperative risk factors for conversion: Mannheim peritonitis index (MPI) > 21 (p = 0.02), generalized peritonitis (p = 0.04), adhesions, and perforations located in a region other than the duodenal anterior wall. We found seven predictive factors for septic complications: age >70 (p = 0.02), cardiopulmonary disease (p = 0.04), ASA > 3 (p = 0.002), CRP > 100 (p = 0.005), duration of symptoms >24 h (p = 0.02), MPI > 21(p = 0.008), and generalized peritonitis (p = 0.02).

CONCLUSION

Our data suggest that a primary laparoscopic approach has no disadvantages. Factors necessitating conversions emerged during the procedure inhibiting a preoperative selection. Factors suggesting imminent septic complications can be assessed preoperatively. An assessment of the proposed parameters may help optimize the management of possible septic complications.

Laparoscopic repair of perforated peptic ulcer: simple closure versus omentopexy

BACKGROUND

This report presents our experience with laparoscopic repair performed in 118 consecutive patients diagnosed with a perforated peptic ulcer (PPU). We compared the surgical outcome of simple closure with modified Cellan-Jones omentopexy and report the safety and benefit of simple closure.

METHODS

From January 2010 to December 2014, 118 patients with PPU underwent laparoscopic repair with simple closure (n = 27) or omentopexy (n = 91). Charts were retrospectively reviewed for demographic characteristics and outcome. The data were compared by Fisher's exact test, Mann-Whitney U test, Pearson's chi-square test, and the Kruskal-Wallis test. The results were considered statistically significant if P < 0.05.

RESULTS

No patients died, whereas three incurred leakage. After matching, the simple closure and omentopexy groups had similarity in sex, systolic blood pressure, pulse rate, respiratory rate, Boey score, Charlson comorbidity index, Mannheim peritonitis index, and leakage. There were statistically significant differences in age, length of hospital stay, perforated size, and operating time. Comparison of the operating time in the ≤4.0 mm and 5.0-12 mm groups revealed that the simple closure took less time than omentopexy in both groups (≤4.0 mm, 76 versus 133 minutes, P < 0.0001; 5.0-12 mm, 97 versus 139.5 minutes; P = 0.006).

CONCLUSIONS

Compared to the omentopexy, laparoscopic simple closure is a safe procedure and shortens the operating time.

INFLUENCE OF THE METHOD OF LAPAROSCOPIC SUTURING OF PERFORATED PYLORODUODENAL ULCERS ON MOTOR-EVACUATION FUNCTION OF THE STOMACH AND DUODENUM IN EARLY POSTOPERATIVE PERIOD

The authors researched the influence of different methods of laparoscopic suturing of perforated pyloduodenal ulcers on motor-evacuation function of the stomach and duodenum in 133 patients with peptic ulcer. There were used different methods such as single-row endo-stitch, two-row endo-stitch, omentopexy. The motor-evacuation function of the stomach and duodenum was studied by roentgenocinescopy in the early postoperative period. It was stated, that frequency and intensity of violation of motor-evacuation functions were reliably low in case of imposing the single-row endo-stitch than using the two-row endo-stitch and the omentopexy in the early postoperative period.

Perforated peptic ulcer - an update

Peptic ulcer disease (PUD) affects 4 million people worldwide annually. The incidence of PUD has been estimated at around 1.5% to 3%. Perforated peptic ulcer (PPU) is a serious complication of PUD and patients with PPU often present with acute abdomen that carries high risk for morbidity and mortality. The lifetime prevalence of perforation in patients with PUD is about 5%. PPU carries a mortality ranging from 1.3% to 20%. Thirty-day mortality rate reaching 20% and 90-d mortality rate of up to 30% have been reported. In this review we have summarized the current evidence on PPU to update readers. This literature review includes the most updated information such as common causes, clinical features, diagnostic methods, non-operative and operative management, post-operative complications and different scoring systems of PPU. With the advancement of medical technology, PUD can now be treated with medications instead of elective surgery. The classic triad of sudden onset of abdominal pain, tachycardia and abdominal rigidity is the hallmark of PPU. Erect chest radiograph may miss 15% of cases with air under the diaphragm in patients with bowel perforation. Early diagnosis, prompt resuscitation and urgent surgical intervention are essential to improve outcomes. Exploratory laparotomy and omental patch repair remains the gold standard. Laparoscopic surgery should be considered when expertise is available. Gastrectomy is recommended in patients with large or malignant ulcer.

The relationship between computed tomography findings and the locations of perforated peptic ulcers: it may provide better information for gastrointestinal surgeons

BACKGROUND

Computed tomography (CT) plays an important role in diagnosing gastrointestinal perforation. This study explored the relationship between CT findings and the locations of perforated peptic ulcers (PPUs), which may help further surgical planning.

METHODS

During a 34-month period, 175 patients had CT scans. We categorized those 175 patients into 2 groups: patients with and without a PPU at a difficult ulcer site for a laparoscopic approach. Both clinical data and the CT images were reviewed and analyzed.

RESULTS

Based on the univariate analysis results, we conducted multivariate analyses of 3 factors: age, American Society of Anesthesiologists classification of 3 or more, and positive lesser sac image findings. The positive lesser sac findings in CT were the only independent factor that was correlated to the PPU site.

CONCLUSIONS

Positive lesser sac CT findings may help to predict PPUs in sites where a laparoscopic approach might be difficult. Our study re-evaluates the additional value of CT scanning in diagnosing PPU, and the results may assist with surgical planning in clinical practice.

Repair of gastric defects with an equine pericardial patch

PURPOSES

The objective of this study was to test the efficacy of an equine pericardial patch for repairing full-thickness defects of the stomach wall.

METHODS

Circular defects, 1.5 cm in diameter, were created on the anterior wall of the stomach of 12 female New Zealand rabbits. The defects were repaired by an equine pericardial patch. After euthanasia at different time intervals (3 days to 8 weeks) a macroscopic evaluation of the abdominal cavity (including adhesion scoring), mechanical testing and a histological examination of the stomach were performed.

RESULTS

The animals survived the surgical procedure and underwent an uneventful recovery until euthanasia. None of the patches failed. Adhesions were observed in all animals and were significant in 3/12 animals. Bursting pressure testing indicated that the repair was durable and that adequate strength to prevent patch failure was achieved by the second week. A histological examination showed gradual narrowing of the perforation site by mucosal and limited muscular regeneration.

CONCLUSIONS

The equine pericardial patch was successfully used to repair a gastric defect in our experimental model, and it seems that it could have potential as a material suitable for further research concerning the repair of upper gastrointestinal defects.

Laparoscopic repair of perforated peptic ulcer: single-center results

BACKGROUND

Perforated peptic ulcer (PPU), the most common indication for emergency gastric surgery, is associated with high morbidity and mortality rates. Outcomes might be improved by performing this procedure laparoscopically, but no consensus exists on whether the benefits of laparoscopic repair (LR) of PPU outweigh the disadvantages.

METHODS

From January 2002 to December 2012, 111 patients underwent surgery for perforated ulcer. A "laparoscopy-first" policy was attempted and then applied for 56 patients. The exclusion criteria for LR ruled out patients who had shock at admission, severe cardiorespiratory comorbidities, or a history of supramesocolic surgery. The aim of this study was a retrospective analysis of the 56 patients treated laparoscopically.

RESULTS

The patient distribution was 30 men and 26 women, who had a mean age of 59 years (range 19-95 years). The mean ulcer size was 10 mm, and the Mannheim peritonitis index (MPI) was 21. LR was performed for 39 (69.6%) of the 56 patients and included peritoneal lavage, suturing of the perforation, and omental patching. Conversion to laparotomy was necessary in 17 cases (30.4%). The "conversion group" showed significant differences in ulcer size (larger ulcers: 1.9 vs. 0.7 mm; p < 0.01), ulcer-site topography (higher incidence of posterior ulcers: 5 vs. 0; p < 0.01), and MPI score (higher score: 24 vs. 20; p < 0.05). The LR group had a mean operating time of 86 min (range 50-125 min), an in-hospital morbidity rate of 7.6 %, a mortality rate of 2.5%, and a mean hospital stay of 6.7 days (range 5-12 days). None of these patients required reintervention.

CONCLUSIONS

The results showed that LR for PPU is feasible with acceptable mortality and morbidity rates. Skill in laparoscopic abdominal emergencies is required. Perforations 1.5 cm or larger, posterior duodenal ulcers, and an MPI higher than 25 should be considered the main risk factors for conversion.

Laparoscopic primary repair with omentopexy for duodenal ulcer perforation: a single institution experience of 21 cases

PURPOSE

Despite the great advances in laparoscopic techniques, most active general surgeons do not apply laparoscopic surgery in the treatment of duodenal ulcer perforation when facing a real-life emergency. Therefore, our study was designed to evaluate the feasibility of laparoscopic surgery in duodenal ulcer perforation, and provide a step-by-step protocol with tips and recommendations for less experienced surgeons.

MATERIALS AND METHODS

Between March, 2011 and May, 2012, 21 patients presenting with duodenal ulcer perforation underwent laparoscopic primary repair with omentopexy. There were no contraindications to perform laparoscopic surgery, and the choice of primary repair was decided according to the size of the perforation. The procedure for laparoscopic primary repair with omentopexy consisted of peritoneal lavage, primary suture, and omentopexy using a knot pusher.

RESULTS

During the operation, no conversion to open surgery or intra-operative events occurred. The median operation time was 45.0 minutes (20~80 minutes). Median day of commencement of a soft diet was day 6 (4~17 days). After surgery, the median hospital stay was 8.0 days (5~27 days). Postoperative complications occurred in one patient, which included a minor leakage. This complication was resolved by conservative management.

CONCLUSIONS

Although our study was carried out on a small number of patients at a single institution, we conclude that laparoscopic primary repair can be an effective surgical method in the treatment of duodenal ulcer perforation. We believe that the detailed explanation of our procedure will help beginners to perform laparoscopic primary repair more easily.

Gastroduodeno-plasty performed by distal gastric transection.- A new technique for large duodenal defect closure

Introduction

Duodenal ulcer lesions can represent a surgical challenge, especially if the duodenal wall is chronically inflamed, the defect exceeds a diameter of 3 cm and the ulceration is located in the second part of the duodenum.

Patient and method

We present the case of a 70-year-old male, who suffered from a 3 x 4 cm duodenal defect caused by duodenal pressure necrosis due to a 12.5 x 5.5 x 5 cm gallstone. Additionally, this stone caused intestinal obstruction (Bouveret’s syndrome) and bleeding with signs of shock. Besides the gallstone extraction, the common bile duct was drained by a T-tube and the duodenal defect closure was performed by a gastroduodeno-plasty and Bilroth II gastroenterostomy. The postoperative phase was uneventful. The reconstructed duodenum was endoscopically accessible and showed no pathological findings on follow-up.

Conclusion

The reconstruction of a large defect (> 3 cm) of the second part of the duodenum is safely feasible by a gastroduodeno-plasty. The critical gastroduodenal anastomosis can be protected by duodenal decompression, achieved by placing a T-tube in the common bile duct.

Laparoscopic simple closure alone is adequate for low risk patients with perforated peptic ulcer

BACKGROUND

Helicobacter pylori (H.P.) eradication has led to a significant decline in peptic ulcer prevalence; however, the number of patients requiring surgical intervention remains relatively unchanged. Laparoscopy suture repair is the most commonly used procedure for perforated peptic ulcer (PPU). Whether omental patch adds any benefit than simple closure alone is not answered.

METHODS

From July 2007 to August 2010, patients received emergency surgeries for PPU in our department were enrolled in this study. The demographic data, disease pattern, surgical outcomes were retrospectively collected. Patients who had previous multiple operations, with profound shock, and complicated ulcers were excluded.

RESULTS

Totally 73 patients were enrolled. 26 of them received simple closure and the other 47 received simple closure plus an omental patch. There were no difference in age, gender, ASA, Boey risk score, and incidence of co-morbidities. The Mannheim Peritonitis index, median operation time and length of stay were not different between groups.

CONCLUSIONS

In terms of leakage rate and surgical outcome, the maneuver to cover an omental patch on the repaired PPU did not show additional advantages compared to simple closure alone. Further prospective randomized study is required to clarify the safety and feasibility of simple closure alone without buttressing an omentum patch.

Management of perforated peptic ulcer in a district general hospital

INTRODUCTION

Laparoscopic surgery has become increasingly popular for elective surgery but it has gained slow transference to emergency surgery. The management of perforated peptic ulcers (PPU) laparoscopically is an accepted strategy yet it still remains infrequently used. The purpose of this study was to analyse the utility and outcomes of laparoscopy versus open repair for PPU in a district general hospital. In addition, we evaluated whether the subspecialty of the on-call consultant affected the method of repair performed and the training opportunities for trainee surgeons.

METHODS

Between 2003 and 2009, 53 patients underwent laparoscopic repair, 89 patients underwent open repair and a further 20 patients had laparoscopic repair that was converted to open repair for PPU. The results from a prospectively compiled database were analysed with primary outcome measures including operative time, length of hospital stay and mortality.

RESULTS

The median operating time in the laparoscopic group was 60.0 minutes compared with 50.5 minutes in the open group. Hospital stay in surviving patients was significantly shorter in patients treated completely laparoscopically (5 days) when compared with the open group (6 days) ( p <0.01). There were six deaths in the laparoscopic group (11%) compared with 13 in the open group (15%) and one in the converted group (5%). Trainees performed 53% (47/89) of open repairs and 13% (7/54) of laparoscopic repairs.

CONCLUSIONS

Both laparoscopic and open repair are equally safe in the management of PPU. Our findings support the view that this procedure can be successfully used as a training operation.

Clinical profile and outcome of surgical treatment of perforated peptic ulcers in Northwestern Tanzania: A tertiary hospital experience

BACKGROUND

Perforated peptic ulcer is a serious complication of peptic ulcers with potential risk of grave complications. There is paucity of published reports on perforated peptic ulcer disease in our local environment. This study was conducted to evaluate the clinical presentation, management and outcome of patients with peptic ulcer perforation in our setting and to identify predictors of outcome of these patients.

METHODS

This was a combined retrospective and prospective study of patients who were operated for perforated peptic ulcers at Bugando Medical Centre between April 2006 and March 2011. Data were collected using a pre-tested and coded questionnaire and analyzed using SPSS computer software version 15.0. Ethical approval to conduct the study was obtained from relevant authority before the commencement of the study.

RESULTS

A total of 84 patients were studied. Males outnumbered females by a ratio of 1.3: 1. Their median age was 28 years and the modal age group was 21-30 years. The median duration of illness was 5.8 days. The majority of patients (69.0%) had no previous history of treatment for peptic ulcer disease. The use of non-steroidal anti-inflammatory drugs, alcohol and smoking was reported in 10.7%, 85.7% and 64.3% respectively. Eight (9.5%) patients were HIV positive with a median CD4 count of 220 cells/μl. Most perforations were located on the duodenum {90.4%) with the duodenal to gastric ulcers ratio of 12.7: 1. Graham's omental patch (Graham's omentopexy) of the perforations was performed in 83.3% of cases. Complication and mortality rates were 29.8% and 10.7% respectively. The factors significantly related to complications were premorbid illness, HIV status, CD 4 count < 200 cells/μl, treatment delay and acute perforation (P < 0.001). Mortality rate was high in patients who had age ≥ 40 years, delayed presentation (>24 hrs), shock at admission (systolic BP < 90 mmHg), HIV positivity, low CD4 count (<200 cells/μl), gastric ulcers, concomitant diseases and presence of complications (P < 0.001). The median overall length of hospital stay was 14 days. Excellent results using Visick's grading system were obtained in 82.6% of surviving patients.

CONCLUSION

Perforation of peptic ulcer remains a frequent clinical problem in our environment predominantly affecting young males not known to suffer from PUD. Simple closure with omental patch followed by Helicobacter pylori eradication was effective with excellent results in majority of survivors despite patients' late presentation in our center.

Single-port laparoscopic repair of a perforated duodenal ulcer: intracorporeal "cross and twine" knotting

BACKGROUND

Single-port laparoscopic surgery is increasingly used to treat various types of diseases requiring surgical intervention. We present the technique and the results of our simple "cross and twine" intracorporeal knotting approach for treatment of a perforated duodenal ulcer.

METHODS

From January 2009 to October 2009, 13 patients with perforated duodenal ulcers underwent single-port laparoscopic repair. The laparoscopic procedure included peritoneal lavage and suture of the perforation. The omentum above the repair site was then reinforced. After surgery, patients took an H2 receptor antagonist for 8 weeks and then underwent follow-up gastrofiberscopy.

RESULTS

All procedures were completed under the conditions described. The mean operative time was 90.2 ± 24.2 min, and the mean hospital stay was 6.1 ± 0.5 days. The mean number of times that opiates were used for pain was 0.5 ± 1.0, and wound length was 1.9 ± 0.1 cm. There was no operation-related morbidity. Follow-up gastrofiberscopy revealed good lesion healing.

CONCLUSIONS

Single-port laparoscopic repair using the "cross and twine" knotting technique is a feasible and safe procedure, and it may be a less invasive laparoscopic surgical technique for scarless surgical treatment of perforated duodenal ulcers.

Laparoscopic correction of perforated peptic ulcer: first choice? A review of literature

BACKGROUND

Perforated peptic ulcer (PPU), despite antiulcer medication and Helicobacter eradication, is still the most common indication for emergency gastric surgery associated with high morbidity and mortality. Outcome might be improved by performing this procedure laparoscopically, but there is no consensus on whether the benefits of laparoscopic closure of perforated peptic ulcer outweigh the disadvantages such as prolonged surgery time and greater expense.

METHODS

An electronic literature search was done by using PubMed and EMBASE databases. Relevant papers written between January 1989 and May 2009 were selected and scored according to Effective Public Health Practice Project guidelines.

RESULTS

Data were extracted from 56 papers, as summarized in Tables 1-7. The overall conversion rate for laparoscopic correction of perforated peptic ulcer was 12.4%, with main reason for conversion being the diameter of perforation. Patients presenting with PPU were predominantly men (79%), with an average age of 48 years. One-third had a history of peptic ulcer disease, and one-fifth took nonsteroidal anti-inflammatory drugs (NSAIDs). Only 7% presented with shock at admission. There seems to be no consensus on the perfect setup for surgery and/or operating technique. In the laparoscopic groups, operating time was significant longer and incidence of recurrent leakage at the repair site was higher. Nonetheless there was significant less postoperative pain, lower morbidity, less mortality, and shorter hospital stay.

CONCLUSION

There are good arguments that laparoscopic correction of PPU should be first treatment of choice. A Boey score of 3, age over 70 years, and symptoms persisting longer than 24 h are associated with higher morbidity and mortality and should be considered contraindications for laparoscopic intervention.

Refractory peptic ulcer disease

Refractory PUD is a diagnostic and therapeutic challenge. Optimal management of severe or refractory PUD requires a multidisciplinary team approach, using primary care providers, gastroenterologists, and general surgeons. Medical management has become the cornerstone of therapy. Identification and eradication of H pylori infection combined with acid reduction regimens can heal ulceration and also prevent recurrence. Severe, intractable or recurrent PUD and associated complications mandates a careful and methodical evaluation and management strategy to determine the potential etiologies and necessary treatment (medical or surgical) required.